Assessing New York City's COVID-19 Vaccine Rollout Strategy: A Case for Risk-Informed Distribution.

This study reviews the impact of eligibility policies in the early rollout of the COVID-19 vaccine on coverage and probable outcomes, with a focus on New York City. We conducted a retrospective ecological study assessing age 65+, area-level income, vaccination coverage, and COVID-19 mortality rates, using linked Census Bureau data and New York City Health administrative data aggregated at the level of modified zip code tabulation areas (MODZCTA). The population for this study was all individuals in 177 MODZCTA in New York City. Population data were obtained from Census Bureau and New York City Health administrative data. The total mortality rate was examined through an ordinary least squares (OLS) regression model, using area-level wealth, the proportion of the population aged 65 and above, and the vaccination rate among this age group as predictors. Low-income areas with high proportions of older people demonstrated lower coverage rates (mean vaccination rate 52.8%; maximum coverage 67.9%) than wealthier areas (mean vaccination rate 74.6%; maximum coverage 99% in the wealthiest quintile) in the first 3 months of vaccine rollout and higher mortality over the year. Despite vaccine shortages, many younger people accessed vaccines ahead of schedule, particularly in high-income areas (mean coverage rate 60% among those 45-64 years in the wealthiest quintile). A vaccine program that prioritized those at greatest risk of COVID-19-associated morbidity and mortality would have prevented more deaths than the strategy that was implemented. When rolling out a new vaccine, policymakers must account for local contexts and conditions of high-risk population groups. If New York had focused limited vaccine supply on low-income areas with high proportions of residents 65 or older, overall mortality might have been lower.

Supply of obstetrician-gynecologists and gynecologic oncologists to the US Medicare population: a state-by-state analysis.

BACKGROUND: The supply of obstetrician-gynecologists and gynecologic oncologists across the United States has been described. However, these studies focused on reproductive-age patients and did not assess the growing demand for services to the advanced-age female population. OBJECTIVE: This study aimed to evaluate the supply of obstetrician-gynecologists and gynecologic oncologists who serve the US Medicare population per 100,000 female Medicare beneficiaries, over time and by state and region. STUDY DESIGN: The supply of obstetrician-gynecologists and gynecologic oncologists was extracted from the Physician and Other Supplier Public Use File database of Medicare Part B claims submitted to the US Centers for Medicare & Medicaid Services. Data were only available from 2012 to 2019. The supply of providers was divided by the number of original female Medicare beneficiaries obtained from the Kaiser Family Foundation; all values reported are providers per 100,000 female beneficiaries by state. Trends over time were assessed as the difference in provider-to-beneficiary ratio and the percentage change from 2012 to 2019. All data were collected in 2021. All analyses were performed with SAS, version 9.4. This study was exempt from institutional review board approval. RESULTS: In 2019, the average number of obstetrician-gynecologists per 100,000 female beneficiaries across all states was 121.32 (standard deviation±33.03). The 3 states with the highest obstetrician-gynecologist-to-beneficiary ratio were the District of Columbia (268.85), Connecticut (204.62), and Minnesota (171.60), and the 3 states with the lowest were Montana (78.37), West Virginia (82.28), and Iowa (83.92). The average number of gynecologic oncologists was 4.48 (standard deviation±2.08). The 3 states with the highest gynecologic oncologist-to-beneficiary ratio were the District of Columbia (11.30), Rhode Island (10.58), and Connecticut (9.24), and the 3 states with the lowest were Kansas (0.82), Vermont (1.41), and Mississippi (1.47). The number of obstetrician-gynecologists per 100,000 female beneficiaries decreased nationally by 8.4% from 2012 to 2019; the difference in provider-to-beneficiary ratio from 2012 to 2019 ranged from +29.97 (CT) to -82.62 (AK). Regionally, the Northeast had the smallest decrease in the number of obstetrician-gynecologists per 100,000 female beneficiaries (-3.8%) and the West had the largest (-18.2%). The number of gynecologic oncologists per 100,000 female beneficiaries increased by 7.0% nationally during the study period; this difference ranged from +8.96 (DC) to -3.39 (SD). Overall, the West had the smallest increase (4.7%) and the Midwest had the largest (15.4%). CONCLUSION: There is wide geographic variation in the supply and growth rate of obstetrician-gynecologists and gynecologic oncologists for the female Medicare population. This analysis provides insight into areas of the country where the supply of obstetrician-gynecologists and gynecologic oncologists may not meet current and future demand. The national decrease in the number of obstetrician-gynecologists is alarming, especially because population projections estimate that the proportion of elderly female patients will grow. Future work is needed to determine why fewer providers are available to see Medicare patients and what minimum provider-to-enrollee ratios are needed for gynecologic and cancer care. Once such ratios are established, our results can help determine whether specific states and regions are meeting demand. Additional research is needed to assess the effect of the COVID-19 pandemic on the supply of women's health providers.

Mortality by occupation and industry among Japanese men in the 2015 fiscal year.

BACKGROUND: Although previous studies have underscored some unique inequalities in occupational mortality in Japan, many of these trends have been dramatically altered during recent decades. We analyzed mortality data by occupation and industry in Japan, to determine whether differences remained by the mid-2010s for men in working-age population. METHODS: We calculated age-standardized all-cause and cause-specific mortality, according to occupation and industry, among men aged 25-64 years in the 2015 fiscal year (1 April 2015 to 31 March 2016). Occupational and industry-specific categories were defined using the Japan Standard Occupational Classification and Japan Standard Industrial Classification, respectively. Age-standardized mortality rates were computed using 5-year age intervals. Mortality rate ratios adjusted for age and 95% confidence intervals (CIs) were estimated using Poisson regression. Cause-specific deaths were classified into four broad groups (cancers [C00-D48], cardiovascular diseases [I00-I99], external causes [V01-Y98], and all other diseases) based on the International Statistical Classification of Diseases 10th Revision (ICD-10). RESULTS: Clear mortality differences were identified by both occupation and industry among Japanese males. All-cause mortality ranged from 53.7 (clerical workers) to 240.3 (service workers) per 100,000 population for occupation and from 54.3 (workers in education) to 1169.4 (workers in mining) for industry. In relative terms, service workers and agriculture, forestry, and fishing workers had 2.89 and 2.50 times higher all-cause mortality than sales workers. Administrative and managerial workers displayed higher mortality risk (1.86; 95% CI 1.76-1.97) than sales workers. Similar patterns of broad cause-specific mortality inequality were identified in terms of both absolute and relative measures, and all broad cause-specific deaths contributed to the differences in mortality by occupation and industry. CONCLUSIONS: Substantial differences in mortality among Japanese male workers, according to occupation and industry, were still present in 2015.

Linkage of national soil quality measurements to primary care medical records in England and Wales: a new resource for investigating environmental impacts on human health.

BACKGROUND: Long-term, low-level exposure to toxic elements in soil may be harmful to human health but large longitudinal cohort studies with sufficient follow-up time to study these effects are cost-prohibitive and impractical. Linkage of routinely collected medical outcome data to systematic surveys of soil quality may offer a viable alternative. METHODS: We used the Geochemical Baseline Survey of the Environment (G-BASE), a systematic X-ray fluorescence survey of soil inorganic chemistry throughout England and Wales to obtain estimates of the concentrations of 15 elements in the soil contained within each English and Welsh postcode area. We linked these data to the residential postcodes of individuals enrolled in The Health Improvement Network (THIN), a large database of UK primary care medical records, to provide estimates of exposure. Observed exposure levels among the THIN population were compared with expectations based on UK population estimates to assess representativeness. RESULTS: Three hundred seventy-seven of three hundred ninety-five English and Welsh THIN practices agreed to participate in the linkage, providing complete residential soil metal estimates for 6,243,363 individuals (92% of all current and former patients) with a mean period of prospective computerised medical data collection (follow-up) of 6.75 years. Overall agreement between the THIN population and expectations was excellent; however, the number of participating practices in the Yorkshire & Humber strategic health authority was low, leading to restricted ranges of measurements for some elements relative to the known variations in geochemical concentrations in this area. CONCLUSIONS: The linked database provides unprecedented population size and statistical power to study the effects of elements in soil on human health. With appropriate adjustment, results should be generalizable to and representative of the wider English and Welsh population.

North by north-west: climate change and directions of density shifts in birds.

There is increasing evidence that climate change shifts species distributions towards poles and mountain tops. However, most studies are based on presence-absence data, and either abundance or the observation effort has rarely been measured. In addition, hardly any studies have investigated the direction of shifts and factors affecting them. Here, we show using count data on a 1000 km south-north gradient in Finland, that between 1970-1989 and 2000-2012, 128 bird species shifted their densities, on average, 37 km towards the north north-east. The species-specific directions of the shifts in density were significantly explained by migration behaviour and habitat type. Although the temperatures have also moved on average towards the north north-east (186 km), the species-specific directions of the shifts in density and temperature did not correlate due to high variation in density shifts. Findings highlight that climate change is unlikely the only driver of the direction of species density shifts, but species-specific characteristics and human land-use practices are also influencing the direction. Furthermore, the alarming results show that former climatic conditions in the north-west corner of Finland have already moved out of the country. This highlights the need for an international approach in research and conservation actions to mitigate the impacts of climate change.

Habitat use by Centropomus undecimalis in a rocky area of estuarine beach in north-east Brazil.

The influence of habitat, diel period, tidal phase and moon phase on the spatial distribution of Centropomus undecimalis was investigated at the mouth of the Timbo estuary, north-east Brazil. Underwater visual censuses were conducted in three areas comprising a mix of mud, sand and beach rock substrata; with one of the areas having additional structural complexity in the form of unused wooden debris. The area with debris housed significantly higher densities of juvenile and adult C. undecimalis whereas sub-adults were more abundant in an area lacking the wooden debris. Juvenile abundance was greatest during the day, whereas sub-adult and adults were more abundant at night. There were significant interactions between habitat, diel period, tidal phase and moon phase for all ages of C. undecimalis. These results emphasize the need to account for a range of environmental factors when planning for the conservation of estuarine and coastal habitats.

A Data Preparation Methodology in Data Mining Applied to Mortality Population Databases.

It is known that the data preparation phase is the most time consuming in the data mining process, using up to 50% or up to 70% of the total project time. Currently, data mining methodologies are of general purpose and one of their limitations is that they do not provide a guide about what particular task to develop in a specific domain. This paper shows a new data preparation methodology oriented to the epidemiological domain in which we have identified two sets of tasks: General Data Preparation and Specific Data Preparation. For both sets, the Cross-Industry Standard Process for Data Mining (CRISP-DM) is adopted as a guideline. The main contribution of our methodology is fourteen specialized tasks concerning such domain. To validate the proposed methodology, we developed a data mining system and the entire process was applied to real mortality databases. The results were encouraging because it was observed that the use of the methodology reduced some of the time consuming tasks and the data mining system showed findings of unknown and potentially useful patterns for the public health services in Mexico.

1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998-2009: a large population study.

BACKGROUND & AIMS: Large, population-based studies that have included the full spectrum of cirrhosis estimating survival, taking into account time-at-risk are lacking. We aimed to report 1- and 5-year average survival rates for people with cirrhosis to be used in a clinical and healthcare policy setting. METHODS: We used the Clinical Practice Research Datalink and linked English Hospital Episode Statistics to identify adult cases of cirrhosis from January 1998 to December 2009. We estimated 1- and 5-year survival according to whether time-at-risk was ambulatory or followed an emergency hospital admission related to liver disease, stratified by age, sex, and aetiology to be used in a clinical setting. We used a multivariate Cox-proportional hazards model with a time-varying variable, adjusted for Baveno IV stage of cirrhosis at diagnosis, age, aetiology, and sex. RESULTS: We identified 5118 incident cases. Average survival probabilities at 1- and 5-years were 0.84 (95% CI 0.83-0.86) and 0.66 (95% CI 0.63-0.68) for the ambulatory group and 0.55 (95% CI 0.53-0.57) and 0.31 (95% CI 0.29-0.33) following hospitalisation, respectively. A hospital admission at diagnosis or subsequently for liver disease substantially impaired prognosis independent of stage of cirrhosis (HR=2.78, 95% CI 2.53, 3.06). CONCLUSIONS: Emergency hospitalisation for liver disease heralds a downturn in a patient's outlook independent of their stage of cirrhosis. Our results provide population-based clinically translatable estimates of prognosis for the purposes of healthcare delivery and planning and communication to patients.

Deaths in the United States among persons with Alzheimer's disease (2010-2050).

BACKGROUND: Alzheimer's disease (AD) profoundly affects the end-of-life experience. Yet, counts of deaths attributable to AD understate this burden of AD in the population. Therefore, we estimated the annual number of deaths in the United States among older adults with AD from 2010 to 2050. METHODS: We calculated probabilities of AD incidence and mortality from a longitudinal population-based study of 10,802 participants. From this population, 1913 previously disease-free individuals, selected via stratified random sampling, underwent 2577 detailed clinical evaluations. Over the course of follow-up, 990 participants died. We computed age-, sex-, race-, and education-specific AD incidences and education-adjusted AD mortality proportions specific to age, sex, and race group. We then combined these probabilities with US-wide census, education, and mortality data. RESULTS: In 2010, approximately 600,000 deaths occurred among individuals aged 65 years or older with AD, comprising 32% of all older adult deaths. By 2050, this number is projected to be 1.6 million, 43% of all older adult deaths. CONCLUSION: Individuals with AD comprise a substantial number of older adult deaths in the United States, a number expected to rise considerably in coming decades.

Temporal trend data (2005-2020) in density and biomass of 13 herbivorous fishes in the Gulf of California.

This dataset comes from a multi-institution compilation of monitoring information for 13 marine herbivorous fishes belonging to six genera of five families: Acanthuridae, Girellidae, Kyphosidae, Pomacentridae and Scaridae, gathered from 2005 to 2020 in the Gulf of California. The database presents a total of 884 records of biomass and density got from 15,542 visual censuses performed using scuba diving in 34 localities comprising 268 rocky and coral reef sites. The censuses consisted of belt transects (250 m2, 100 m2, and 60 m2) laid parallel to the coastline, where expert monitors recorded the abundance of all observed adult individuals of the 13 target herbivorous species, and visually estimated the total length (cm) of each fish. In the database, the information for each transect is presented in the form of average fish density (individuals/m2) and biomass (g/m2), the latter was estimated based on the abundance and size per individual and the published weight-length relationship for each species. Also, we present the latitude and longitude of each locality, type of management, localities in the Gulf of California, institutions, the initial and final year of data, total number of years, as well as the mean, standard deviation, sample size, slope (annual rate of change), probability value, standard error and minimum and maximum value calculated for each species within each locality. This dataset represents an historical baseline of the status of the 13 species in the Gulf of California and can be used to conduct analyses of temporal and spatial trends in herbivorous fish assemblages, considering tropicalization of the interest region due to global change. Moreover, this data will provide key information to stakeholders and managers of protected areas along the gulf and the eastern tropical Pacific region.

Establishing large mammal population trends from heterogeneous count data.

Monitoring population trends is pivotal to effective wildlife conservation and management. However, wildlife managers often face many challenges when analyzing time series of census data due to heterogeneities in sampling methodology, strategy, or frequency. We present a three-step method for modeling trends from time series of count data obtained through multiple census methods (aerial or ground census and expert estimates). First, we design a heuristic for constructing credible intervals for all types of animal counts including those which come with no precision measure. Then, we define conversion factors for rendering aerial and ground counts comparable and provide values for broad classes of animals from an extant series of parallel aerial and ground censuses. Lastly, we construct a Bayesian model that takes the reconciled counts as input and estimates the relative growth rates between successive dates while accounting for their precisions. Importantly, we bound the rate of increase to account for the demographic potential of a species. We propose a flow chart for constructing credible intervals for various types of animal counts. We provide estimates of conversion factors for 5 broad classes of species. We describe the Bayesian model for calculating trends, annual rates of population increase, and the associated credible intervals. We develop a bespoke R CRAN package, popbayes, for implementing all the calculations that take the raw counts as input. It produces consistent and reliable estimates of population trends and annual rates of increase. Several examples from real populations of large African mammals illustrate the different features of our method. The approach is well-suited for analyzing population trends for heterogeneous time series and allows a principled use of all the available historical census data. The method is general and flexible and applicable to various other animal species besides African large mammals. It can readily be adapted to test predictions of various hypotheses about drivers of rates of population increase.

Significant Geographic Variation in Access to Certified Collagenase Clostridium histolyticum Injectors for Peyronie's Disease Throughout the United States.

INTRODUCTION: We characterize the geographic distribution of providers trained to inject Clostridium histolyticum and identify areas with low provider availability. METHODS: We utilized a publicly available search tool to identify clinical sites offering Clostridium histolyticum in the US The data gathered included the provider's name, specialty, address, and whether the site was considered high-volume (ie, administer ≥20 Clostridium histolyticum injections per year). Data were compared to the AUA Census. RESULTS: In total, 2,388 clinical sites offering Clostridium histolyticum were identified. A total of 894 sites (37%) were high-volume sites. The mean number of locations offering Clostridium histolyticum per 100,000 state residents was 0.69 (SD 0.27). Georgia (1.28), Rhode Island (1.13), and Alaska (1.10) had the highest number, whereas New Mexico (0.10), Maine (0.22), and Delaware (0.30) had the lowest. The mean proportion of urologists providing Clostridium histolyticum to total urologists was 0.17 (SD 0.07). The 3 states with the highest proportion were Georgia (0.37), Alaska (0.31), and Utah (0.30), whereas New Mexico (0.03), Maine (0.05), and Vermont (0.06) had the lowest. CONCLUSIONS: States with low numbers of clinical sites offering Clostridium histolyticum per 100,000 residents relative to other states also had a low total ratio of urologists offering Clostridium histolyticum as a treatment. There is room for urologists in these states and others to expand their practice to offer Clostridium histolyticum and improve patient access to this important nonsurgical treatment option.

Age and Sex Distributions of 31 Common Racial Groups in Hawai'i: A Shiny Web Application.

Hawai'i is the most ethnically diverse state with the highest proportion of multiracial individuals in the United States. The Stepwise Proportional Weighting Algorithm (SPWA) was developed to bridge the categorization of multiracial Census data into single-race population estimates for common races in Hawai'i. However, these estimates have not been publicly available. A Shiny web application, the Hawai'i Single-Race Categorization Tool, was developed as a user friendly research tool to obtain the age and sex distributions of single-race estimates for common racial groups in Hawai'i. The Categorization Tool implements the SPWA and presents the results in tabular and graphic formats, stratified by sex and age. It also allows the categorization of partial Native Hawaiians as Native Hawaiians in the population estimation. Using this tool, the current paper reports population estimates and distributions for 31 common racial groups using Hawai'i Census 2010 data. Among the major Census races, Asian had the largest population (631 881; 46.5%) in Hawai'i, followed by White (431 635; 31.7%) and Native Hawaiian and Other Pacific Islander (227 588; 16.7%). Among Census detailed races within Asian, Filipino had the largest population estimate (244 730; 18.0%), followed by Japanese (227 165; 16.7%) and Chinese (103 600; 7.6%). Native Hawaiian accounted for 12.3% of the Hawai'i population (166 944). After recategorizing part-Native Hawaiians as Native Hawaiians, Native Hawaiian increased by 150.0%, with the greatest increase among the young. This publicly available tool would be valuable for race-related resource allocation, policy development, and health disparities research in Hawai'i.

Stepwise Proportional Weighting Algorithm for Single-Race Population Estimation Using Hawai'i Census Data.

Many health and health disparities studies require population prevalence information of various race groups, but the estimation of single-race population sizes using the US Census data has been challenging. For each Census race group, Census only provides the counts of those reported being single race ("race alone") and those reported of that specific race regardless of whether the individuals were multiracial or not ("race alone or in (any) combination"). The issue of how to classify Census multiracial individuals is especially important for the state of Hawai'i due to its large multiracial population. The current study developed the Stepwise Proportional Weighting Algorithm (SPWA) for single-race population estimation using US Census data for major race groups in the Census and their nested detailed races. Additionally, given that "partial Native Hawaiian" has often been treated as "Native Hawaiian" in health disparities studies in Hawai'i, the algorithm can also adjust for the unique partial Native Hawaiian race categorization. This paper describes the estimation process with the SPWA and demonstrates its ability to estimate single-races for the 5 most common race groups in Hawai'i. This new methodology addresses an important concern regarding how to classify multiracial individuals to strengthen health and health disparities research in Hawai'i.

Characterizing tree trait variance over spatiotemporal scales.

Beyond the study of the mean, functional ecology lacks a concise characterization of trait variance patterns across spatiotemporal scales. Traits are measured in different ways, using different metrics, and at different spatial (and rarely temporal) scales. This study expands on previous research by applying a ubiquitous and widely used empirical model-Taylor's Power Law-to functional trait variance with the goal of identifying general patterns of trait variance scaling (the behavior of trait variance across scales). We compiled data on tree seedling communities monitored over 10 years across 213 2 m2 plots and functional trait data from a subtropical forest in Puerto Rico. We examined trait-based Taylor's Power Law at nested spatial and temporal scales. The scaling of variance with the mean was idiosyncratic across traits suggesting that the drivers of variation are likely to differ across traits that may make variance scaling theory elusive. However, slopes varied more in space than through time, suggesting that spatial environmental variability may have a larger role in driving trait variance than temporal variability. Empirical models that characterize taxonomic patterns across spatiotemporal scales, like Taylor's Power Law, can provide an insight into the scaling of functional traits, a necessary next step toward a more predictive trait-based ecology.

Professional Burnout of Advanced Practice Providers Based on 2019 American Urological Association Census Data.

INTRODUCTION: Burnout has been recognized as an occupational hazard among health care professionals. The objective of this study was to assess the extent and pattern of burnout in advanced practice providers (APPs) in urology by analyzing American Urological Association Census data. METHODS: The American Urological Association conducts an annual census survey to all providers in the urological care community, including APPs. In the 2019 Census, the Maslach Burnout Inventory questionnaire was included to measure burnout among APPs. Demographic and practice variables were assessed to establish correlating factors to burnout. RESULTS: A total of 199 APPs (83 physician assistants and 116 nurse practitioners) completed the 2019 Census. Slightly more than 1 in 4 APPs experienced professional burnout (25.3% in physician assistants and 26.7% in nurse practitioners). Observed higher burnout rates were seen in APPs who were aged 45 to 54 (34.3%), women (29.6% vs 10.8% in men, p value <0.05), non-White (33.3% vs 24.9% in White), those who had 4-9 years of practice (32.4%) and those who practiced in academic medical centers (31.7%). Except for gender, none of the above observed differences were statistically significant. Using a multivariate logistic regression model, gender remained the only significant factor associated with burnout (women vs men with an odds ratio of 3.2 [95% confidence interval: 1.1-9.6]). CONCLUSIONS: Overall, APPs in urological care reported lower levels of burnout than urologists; however, there was a higher chance of female APPs experiencing higher professional burnout in comparison to their male counterparts. Future studies are needed to investigate possible reasons for this finding.

Describing and assessing a new method of approximating categorical individual-level income using community-level income from the census (weighting by income probabilities).

OBJECTIVE: To assess a new approach (weighting by "income probabilities [IP]") that uses US Census data from the patients' communities to approximate individual-level income, an important but often missing variable in health services research. DATA SOURCES: Community (census tract level) income data came from the 2017 5-year American Community Survey (ACS). The patient data included those diagnosed with cancer in 2017 in Ohio (n = 65,759). The reference population was the 2017 5-year ACS Public Use Microdata Sample (n = 564,357 generalizing to 11,288,350 Ohioans). STUDY DESIGN/METHODS: We applied the traditional approach of income approximation using median census tract income along with two IP based approaches to estimate the proportions in the patient data with incomes of 0%-149%, 150%-299%, 300%-499%, and 500%+ of the federal poverty level (FPL) ("class-relevant income grouping") or 0%-138%, 139%-249%, 250%-399%, and 400%+ FPL ("policy-relevant income grouping"). These estimated income distributions were then compared with the known income distributions of the reference population. DATA COLLECTION/EXTRACTION METHODS: The patient data came from Ohio's cancer registry. The other data were publicly available. PRINCIPAL FINDINGS: Both IP based approaches consistently outperformed the traditional approach overall and in subgroup analyses, as measured by the weighted average absolute percentage point differences between the proportions of each of the income categories of the reference population and the estimated proportions generated by the income approximation approaches ("average percent difference," or APD). The smallest APD for an IP based method, 0.5%, was seen in non-Hispanic White females in the class-relevant income grouping (compared with 16.5% for the conventional method), while the largest APD, 7.1%, was seen in non-Hispanic Black females in the policy-relevant income grouping (compared with 18.0% for the conventional method). CONCLUSIONS: Weighting by IP substantially outperformed the conventional approach of estimating the distribution of incomes in patient data.

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys.

Background: Analysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist. Methods: Analysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken. Findings: In 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7-0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6-0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6-0.7 and PR = 0.65; 95% IC: 0.6-0.7 respectively), compared with the majority ethnic group in the country. Interpretation: While the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed. Funding: This paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

Distribution and Retention Trends of Obstetricians and Gynecologists in Japan: A Longitudinal Study.

INTRODUCTION: This longitudinal study aimed to investigate the distribution and retention of obstetricians and gynecologists in Japan. METHODS: I used descriptive statistics and multivariate logistic regression to analyze data from National Census surveys administered during 1996-2016. RESULTS: Between 1996 and 2016, the number of obstetricians and gynecologists increased by 6% and urban physicians by 15%, whereas the number of rural physicians decreased by 25%. The annual retention rate, which was calculated using the square root of the biannual rates [the number of physicians still working as obstetricians and gynecologists at the time of the subsequent survey (e.g., in 1998) divided by the number of obstetricians and gynecologists in the original survey (e.g., in 1996)], was >90%. Obstetricians and gynecologists were less likely to continue to work as obstetricians and gynecologists after 30-44 years of experience (1996-2006 cohort: OR = 0.20, 95% CI = 0.17-0.25; 2006-2016 cohort: OR = 0.32, 95% CI = 0.25-0.41) and >45 years of experience (1996-2006 cohort: OR = 0.14, 95% CI = 0.11-0.17; 2006-2016 cohort: OR = 0.11, 95% CI = 0.08-0.15). The odds were lower for rural obstetricians and gynecologists (1996-2006 cohort: OR = 0.65, 95% CI = 0.51-0.82; 2006-2016 cohort: OR = 0.59, 95% CI = 0.43-0.80). As the number of female physicians increased, the number of practicing obstetricians and gynecologists also increased. In 2004, the mandatory postgraduate clinical training that was newly implemented caused a drop in the number of young doctors; however, this reversed in 2006. Rural to urban migration was steady, and the working hours were consistently long. To stabilize high retention rates, the working environments need to be improved. CONCLUSIONS: The present study clearly indicated the trend of the distribution of obstetricians and gynecologists in Japan. The result may be especially important for the health policy making in Japan.

The Gender Pay Gap in Urology.

INTRODUCTION: Female physicians earn less than males in every medical specialty. We sought to determine whether a pay gap existed in urology and explore potential associated factors. METHODS: We used 2,323 responses to the 2017 American Urological Association census to represent all 12,517 U.S. urologists. We limited analysis to ages 34 to 65 and matched on years in practice. We explored the association between self-reported salary (more than $350,000 vs less than $350,000) and gender using multivariable logistic regression adjusted for age and practice. RESULTS: On bivariate analysis males were more likely to make more than $350,000 (56.9% vs 39.7%, p=0.01). There were no gender differences in weekly clinical (43.1 female vs 46.9 male, p=0.13) or nonclinical hours (7.9 female vs 9.1 male, p=0.23). Men do more inpatient procedures per month (7.8 vs 5.6, p=0.02) and more patient visits per week (78.4 vs. 68.4, p=0.04). Women spent more time with each patient (17.6 vs 14.9 minutes, p <0.01). On unadjusted logistic regression men were more likely to earn more than $350,000 (OR 2.01, p=0.02). On multivariable regression, gender was no longer significant (OR 1.59, p=0.11). Factors associated with earning more than $350,000 include more clinical/fewer nonclinical hours, shorter/more office visits, more inpatient surgeries, private practice, subspecialty training, Northeast location and nonWhite race. CONCLUSIONS: This analysis suggests a gender pay gap. While men and women work equal hours, women urologists are more likely to work in less profitable settings, perform fewer inpatient procedures and see fewer patients. Future research needs to understand whether women choose these practices or whether external factors compel them to do so.